Vulvovaginitis, candidal

Vulvovaginitis (also Vulvitis) 616.10
Vulvovaginitis, amebic 006.8
Vulvovaginitis, chlamydial 099.53
Vulvovaginitis, gonococcal (acute) 098.0
Vulvovaginitis, gonococcal, chronic or duration of 2 months or over 098.2
Vulvovaginitis, herpetic 054.11
Vulvovaginitis, monilial 112.1
Vulvovaginitis, trichomonal (Trichomonas vaginalis) 131.01

DESCRIPTION

Vulvar pruritus and/or burning, often with abnormal vaginal discharge

System(s) affected: Reproductive, Skin/Exocrine

Genetics: N/A

Incidence/Prevalence in USA

• 40% of vulvovaginitis is caused by Candida
  
• 16% of non-pregnant premenopausal women are asymptomatic carriers Predominant age: Menarche to menopause Predominant sex: Female only SIGNS AND SYMPTOMS
• Intense vulvar itching
• Thick curd-like vaginal discharge
• Dyspareunia at times
• Erythema of vulva
• Erythema, pain and pruritus of crural and perineal area
• Thick white patches appear attached to vaginal mucosa
• Inflamed vulvar skin CAUSES Overgrowth of Candida species (C. albicans, C. glabrata, C. tropicalis) in vagina RISK FACTORS
• Pregnancy
• Diabetes mellitus
• Antibiotic therapy
• Corticosteroid therapy
• Immunosuppressed states
• HIV infection
• Occlusive synthetic underpants and undergarments
• Hypothyroidism
• Oral contraceptive medications (low dose usually not a cause of increased infection risk)
• Anemia
• Zinc deficiency DIAGNOSIS DIFFERENTIAL DIAGNOSIS
• Trichomonas vaginitis
• Gonorrheal vaginitis - in prepubertal girls
• Pinworm vaginitis
• Contact dermatitis/vaginitis LABORATORY
• Yeast, spores, and/or pseudohyphae on smear with 10% KOH solution
• Culture findings on Nickerson's or Sabouraud's media; usually only indicated for recurrent infections
• Vaginal pH < 4.5 DIAGNOSTIC PROCEDURES
• Smear of discharge with 10% KOH solution
• Pap smear TREATMENT APPROPRIATE HEALTH CAREOutpatient GENERAL MEASURES
• Remove foreign body if one present
  
• Consider povidone-iodine (Betadine, Operand) douche 15 to 30 mL/L (2 tbsp/qt) of water for symptomatic relief until specific therapy is effective
  
• If urination causes burning, have the patient
  
  
  • Urinate through a tubular device such as a toilet-paper roll or plastic cup with the end cut out
    
  • Pour warm water over vaginal area while urinating
• Insist on strict diabetic control if patient is diabetic ACTIVITY
• Avoid overexertion, heat, and excessive sweating
  
• Delay sexual relations until symptoms clear DIETLimit sweets (sucrose) and dairy products (lactose) in recurrent infections PATIENT EDUCATION
• Keep the genital area clean. Use plain unscented soap.
  
• Take showers rather than tub baths
  
• Wear cotton underpants with a cotton crotch. Avoid clothing made from non-ventilating materials, including most synthetic underclothing. Avoid tight-fitting jeans or slacks
  
• Sleep in loose gown without underpants
  
• Don't sit around in wet clothing - especially a wet bathing suit
  
• Avoid frequent douches
  
• Avoid broad-spectrum antibiotics when possible
  
• After urinating or bowel movements, cleanse by wiping or washing from front to back (vagina toward anus)
  
• Lose weight, if obese
  
• American College of Obstetricians & Gynecologists (ACOG), 409 12th St., SW, Washington, DC 20024-2188, (800)762-ACOG MEDICATIONS DRUGS OF CHOICE
• Fluconazole (Diflucan): 150 mg po once
  
• Miconazole nitrate (Monistat): one suppository q night x 3, or miconazole vaginal cream q night x 7, or
  
• Butoconazole nitrate (Femstat): vaginal cream q night x 3, or
  
• Terconazole (Terazol): one suppository or vaginal cream q night x 3, or
  
• Clotrimazole (Gyne-Lotrimin): two 100 mg tablets intravaginally x 3 days or cream each night x 7 days Contraindications: N/A Precautions:
• Use fluconazole with caution in patients with liver disease Significant possible interactions: Refer to manufacturer's profile of each drug ALTERNATIVE DRUGS
• Retreat with different agent, if recurrence
  
• Course of oral nystatin; 100,000 units tid for 2 weeks
  
• Topical gentian violet 1% aqueous solution painted onto vagina weekly until infection resolves (usually 2-3 weeks)
  
• Boric acid 600 mg in gelatin capsule inserted vaginally daily for 2 weeks. FOLLOWUP PATIENT MONITORINGGenerally no specific followup needed. If symptoms persist, then repeat pelvic exam and culture. PREVENTION/AVOIDANCE
• Follow instructions under patient education
  
• For recurrences consider reinfection from sexual partner(s). Examine and treat sex partner for Candida balanitis and oral Candida if vaginitis recurs.
  
• Review Risk Factors POSSIBLE COMPLICATIONSSecondary bacterial infections of the vagina or vulva EXPECTED COURSE/PROGNOSIS
• Complete cure with vigorous treatment
  
• Recurrences are common MISCELLANEOUS ASSOCIATED CONDITIONSSexually transmitted diseases AGE-RELATED FACTORS Pediatric: Less common before puberty Geriatric: N/A Others: N/A PREGNANCYCommon SYNONYMS
• Monilial vulvovaginitis ICD-9-CM112.1 Candidiasis of vulva and vagina Author(s)
  Albert T. Shiu, MD